#welovetheNHS

We all love the NHS. So much so that when it was slurred in the context of an American political debate thousands of people inventively hollered their support from cyberspaces newest technological rooftop.

We love the NHS for one simple reason. It is universal - Simply put it means the same to all of us; healthcare when we need it without regard to our material or social position. The NHS is the most true monument to the thinking which underpinned the development of the welfare state; All citizens, not just those who succeed via the free market, possessing rights; rights to education, rights to health, rights to live a fulfilled life.

Well, there are two reasons we love the NHS. The second is that despite Thatchers attempts at destabilisation in the late 1980s it delivers a high standard of care. Though to be fair to myself this is linked much more closely with universalism than is first thought. Universal services tend to be of higher quality and like the NHS are far more resilient to Politicians cutting funding. Cut Jobseekers allowance - the unemployed suffer. Cut a local hospitals budget we all suffer.

So what are we to make of the Government's suggestion for a "National Care Service". The name choice seems like a supermarket own-brand cola brands attempt at aping coca-colas distinctive packaging - in effect branding piggybacking; in this case suggestive of the national standard and universal entitlements of our beloved NHS. But will we be getting the real thing or a cup of water with a spoonful of sugar and a drop of food dye?

Social Care on the other hand combines universalism with it's opposite number selectivism. We are all entitled to an assessment and to services but when it comes to funding services this is by way of means-testing which varies across local authorities and can be in some cases quite punitive, by the Government's own admission penalising those on middle-incomes or with savings. The Government's plans keep this structure in place for the vast majority of service users but add an outhouse of universalism for the much lower number of people with the highest level of need. Local authorities will also still be in charge of delivering services which will mean that National standards will be logistically hard to implement and postcode lottery most likely to be the result.

As this article points out the National Care Service idea seems to have materialised from nowhere. There was certainly no talk of it when I was still in an authourity at the tail end of last year. Which all begs the question... just what is going on?

I beleive there is a divorce taking place between care management and social work. If the kind of initiatives I have seen piloted in the last couple of years such as individual budgets, self-assessment and care management being carried out by voluntary sector 'Brokers' works out as planned then Government can scale back their involvement in this area, concentrating instead on service users with high-level and complex cases which are primarily the realm of qualified social workers. A National Care Service encompasing only this latter area and which overlaps with the NHS and its universal ethos would certainly be a way of creating a framework in which this could be achieved.

This would be entirely consistent with what has been happening at a local level. Since the 1980s local authourities have increasingly outsourced. Beginning with workers in peripheral activities and/or at the bottom of local government pay scales, cleaners, cooks, carers, the tide has been rising higher up the pay grades, council tax officers, finance officers, IT technicians, HR, payroll are now likely to be found with ID badges bearing the tell-tell words of privitisation: 'working with.' The future is I beleive one where authourities will consist of a rump of qualified professionals involved in complex cases or enforcement functions; town planners, highway engineers, and social workers who will direct and supervise work carried out by outsourced non-qualified staff.

Closing the gap

The depressing news that inequality is today worse than the 1970s comes as little surprise. One of the points made in the BBC report is how this is embarrasing for a government which has set out with the aim of tackling inequality.

I am reminded that a couple of years ago my directorate listed 'closing the gap' among its core aims. Its fate was to be eventually dropped by an incoming Conservative administration but for the couple of years of its tenure it seemed a noble objective.

In my experience however, the authority did little to reach out across barrriers. Changes were introduced so leaflets in surgeries and other locations disappeared in favour of 'factsheets' online and translated leaflets became only available on request. The service became in effect only visable to those who had the resources to search for it. Service users on low to middle incomes also faced the biggest squeeze when the financal assesment procedures were overhauled.

The trouble is that the policy aims were like a piece of soviet-era rhetoric, a doctrine of equality preached by a comfortably-off political class with no real commitment to them apart from as a smokescreen. I once quizzed our Executive Director about how a policy which could be detrimental to this aim could be amended to take equality into consideration only to be told, reveallingly, that 'social levelling' was not the aim of the policy in question. This left me to wonder what the point of aims, charters and in my authourity's best jargon 'golden-threads' (the process by which the core aims filtered down to ground level actions) are apart from to impose a layer of hyper-reality where we supposedly work towards an aim but by our actions move ever further from it.

Social-care has a crucial role to play in pushing for greater equality. In my city it was no accident that the busiest team covered the worst-off area of the city. There are undisputed links between poverty and poor health. Conditions such as COPD and diabetes are more likely to affect the poorest. We need a more pro-active social care agenda which is not afraid to question policies, to empower individuals and communities, and to find new ways of working with education, health and other services to prevent needs arising. But, we can only do this if we mean it, if we really care about closing the gap.

Predictions

In the last week I've reached a milestone. I now automatically write the date as 2010, no longer is my official correspondance besmirched by a scruffily scrubbed out 09.

Social care is also at something of a milestone. Twenty years since the last major piece of legislation the 1990 NHS and Community Care Act.

Interestingly major legislation appears to come neatly in two decade cycles. The 1948 NA act and 1970 CSDP act both preceding the 1990 act. In terms of adult services this previous legislation has remained on the statute book - there has never been a clean sweep of the legislative broom with the result that the legislative framework takes on a the architectural characteristics of Hampton Court Palace with wings added, rooms refurbished, new facades and repaired fire damage. Can we expect another addition to this mix in the next few years and if so what shape will it take?

There has been an attitude shift at the heart of the welfare state. Beneficiaries are no longer the passive recipients of the Beveridge era but are in policy terms becoming 'active' This is very much a rights and responsibilities issue and has been seen so far in unemployment benefit where recipients are expected to enter into a contract to actively look for work and update their skills. For social care it will mean a shift in emphasis from a care manager planning a care package and providing services contracted through the local authourity; instead it will mean an individual deciding on their own sources of support and managing this. In other words a person will have a right to care but the responsibility to plan and arrange it.

I also expect the way in which care is funded to change. My initial reading had been that there was an expectation that the cash locked in glacial-like block contracts would as they melted in the new climate mingle with funding streams from the voluntary and private sectors to create a fertile valley of healthy diverse services resulting in savings. This expectation was wildly optimistic. The cheapest way of providing services is by uniform en-masse block contracts with in-built economies of scale. I wouldn't be surprised to see a modified AA and DLA given more of a centre-stage role when it comes to funding care packages and longer term beleive there may well be a move toward a social-insurance type scheme with a degree of state and private sector involvement. I also expect the directly paid workforce in local authorities to be reduced to social workers focused on safeguarding work and a rump of care managers focused on auditing and approving care packages with activities such as setting up care, dealing with minor issues and completing assessment forms to be carried out by the voluntary sector.

It is impossible to predict however, whether these changes will be good or bad. There are certainly concerns. My biggest concern would be middle-class opt-out. Under personalisation the middle class who can top-up may opt out leaving those less well off or with complex needs in receipt of residual services - possibly offered by a local authourity as a 'safety-net'. In social policy there is a wealth of literature to suggest middle class opt-out has huge negative affects on services which become more succeptible to funding cuts. Just think about the arguements that schools fail when the middle class pull their children out.

This and other issues remain a question of government. Both parties favour personalisation. It is a curious issue where the critique of the right has informed the actions of the left. The parties will I beleive differ in their emphasis on elements of the policy with the Tories true to type favouring a more private sector based funding resolution wheras Labour will favour the road of voluntary sector partnerships.

Happy New Year

A slightly belated happy New Year to everyone and welcome to a new decade. In the spirit of the time of year I will offer a review of the year as it has affected me personally and professionally before I look into my social care crystal ball to offer some predictions for the year or decade to come.

Firstly the personal and professional. 2009 saw me finally get my break as an unqualified care manager via a secondment opportunity from mid-January to mid-October. I then ended my almost five year association with the authority at the end of October. The end came as I had two years previously, fresh out of a relationship and into career doldrums, decided to apply for an MSc in Social Policy which I deferred for a year. Just after taking up my place at the beginning of October, using reserves of annual leave to attend lectures, I was interviewed for and offered a permanent care management post, the catch was that they couldn’t accommodate my request for part-time hours. This resulted in an agonising overnight decision with much tossing and turning in bed. I had been attempting since 2006 to obtain a care management post but I had started the MSc and was enjoying it as policy had been a particular interest of mine. I decided that my long-term goal of a job in a policy capacity would best be achieved by remaining on the course. I also felt the need of a change of scenery to rejuvenate me so I handed in my notice.

As of now I am still on the course, I am also achieving pass marks but, as it has been seven years since my last determined academic effort I have found the going tough. The Christmas break ended today and I have a deadline approaching in a couple of weeks for an essay on New Social Risks. I am working harder than ever before, working in a call centre four days a week and spending late nights in the library. I have now cut work down to three days and have had a chance to relax a bit over Christmas – though it has awakened memories of being able to put my feet up in the evenings.

Part of my course has involved learning about comparative social policy, the practice of comparing welfare regimes across the continent. The logic of this is that there is only so much you can learn about a welfare state by studying it in isolation. So it is with work. Leaving the field has been a learning experience in itself. In my call centre role, the one change I notice is the lack of pressure. This struck me just before Christmas. Local weather conditions conspired to leave the city resembling an ice rink in the morning. As I slid to work amidst surreal scenes of abandoned cars and pedestrians trudging in the road, car and bicycle travel an impossibility, I passed a warden assisted block. I suddenly thought of my former colleagues. Some of them would have arrived in the office, found half their colleagues hadn’t been able to get in. Then the calls would begin. Carers would be unable to get into work so clients would not get their visits. Med prompts, meals and personal care would be seriously delayed or missed. Someone would need to establish which calls were really, really essential and try to get a stretched Rapid Response team to visit. The day care bus wouldn’t have been able to get round, people would need to have something to eat as they wouldn’t eat at day centre, Meals on Wheels would also be affected so that wouldn’t be an option……… I sent one of my friends in my old team a text to say I was thinking of her. I knew what sort of day she would be having. Heroic.

Language games

What is the correct term for a person who has involvement with the social care sector? In my experience there was in practice no real concrete guidance, individuals largely left to make their own decisions, though like a swarm of bees almost everyone settled on ‘client’, or ‘service user’. In the case of joint working teams the medical professionals stuck resolutely to their classic label of ‘patient’.

The lack of guidance is surprising as the terms we use to describe people are often highly loaded, crystallising the whole histories of professions and influencing the way practitioners relate to the people they work with. Patient, the dominant term in medicine, is regarded by suspicion by social care carrying as it does connotations of passivity in the face of the all conquering medical paradigm. I also find service user difficult as many people I came into contact with were not, or did not wish to be, in receipt of any services.

It is client however, which I have enormous difficulty with. On one hand it does distribute power more evenly between an individual and the organisation, but its origins are rooted in the consumerist conception of the welfare state which I regard with some suspicion. When we speak of clients we imagine somebody who is purchasing a service and entering into a contract. Fine. Perhaps. This view has delivered some improvements through increasing choice and accountability, but at the cost of increasing means-testing. ‘Clients’ increasingly do - literally purchase their care with the Local Authourity acting as broker. Services such as care are no longer a right more an option; if you wish to pay for it. It’s often struck me as an unfair that if you require medical treatment, the state will, quite rightly, cover the cost of this. However, if you happen to need a carer to enable you to go about your daily life, this can be at the cost of a large portion, or in other cases all, of your savings and income. The term client is less innocent than it appears, but is it possible to have a world without such labels?

The downside to professionalisation

I've been in an essay mode recently, a condition a friend once referred to as 'nesting', I'm surrounded by paper; handwritten lecture notes, books, photocopied chapters, and memos scrawled in a desperate attempt to capture inspiration like a delicate butterfly in a net. I plan to enjoy a weekend of relaxation before clearing the floor ready for my next essay due in two weeks time. No doubt this scene is being replicated in rooms across the country. From Newcastle to Exeter invitations shunned, partners asked for understanding and sacrifices being made in the hope that a good grade means a better future.

From 2012 a three or four year university degree will be the only route of entry to the nursing profession. I have mixed feelings about this. I wrote an essay on the nursing profession as an undergraduate in the early noughties about the politics of the profession. It didn't get me a good grade, but it introduced me to the debate in nursing between on one hand the Florence Nightingale School of nursing which emphasised the pastoral, caring side of nursing and the Mrs Bedford Fenwick school which argued for minimum training standards, registration and increased professionalism. These polar positions have endured through the creation of a universal NHS and can be clearly seen the views put forward today by the RCN and the Patients Association.

For me I feel that both elements have a point. I recognise that the health service has moved on and requires increased specialist skills, but I cannot help agreeing with some of the views expressed on the BBC 6 o'clock news that a 3 or 4 year degree format may put many potentially good nurses off entering the profession. In many ways the story of Nursing and Social Work are similar, both can trace their early development to Victorian amateur pioneers, both have struggled with gender discourses and both have seen groups fighting for increased professional recognition.

One issue in social care has been the creation of a two-tier workforce with unqualified workers experiencing reduced status - as humorously documented in Clare in the Community (October 10th 2007) , fewer development opportunities, and career ceilings. All of which leads to workers with years of experience leaving the field rather than opting to take a three or four year degree. The importance of unqualified workers is often ignored, even in papers such as the Guardian; they rarely appear in accounts which talk of 'the profession'. I was shocked when I first walked into my office to discover that in a team of around 12 there were only two qualified Social Workers, one being the team manager, so in terms of front line workers there was only one qualified Social Worker. It is not my intention here to critique the Social Work degree. My point is that raising barriers to a profession can be problematic. I have had the pleasure of working with many dedicated and competent unqualified workers, who would be regarded as social workers in other parts of the world, many who could have so much more to offer.

In the name of liberal democracy..

My feet have gone beyond aching, but finally after months of build-up, which has led to a few things this blog included being neglected, it's over. I'm promising myself never, never, never-ever again just like I did last year, but this time I mean it. I haven't run a marathon or gone for an agonisingly long hill-laden distance bike ride, no; I've just been collecting peoples names for the register of electors.

It all starts in August. A couple of pleasant sunny mornings spent posting letters containing the forms through peoples doors. Just as the leaves are turning yellow come the reminders in September. Then October; Stage 3 - the door knocking stage. Stage 3 involves knocking on the door of every non-responding address twice. The statutory time frame for this is the 9th - 26th October. The sociology graduate in me finds this stage interesting. The Chicago School of Urban Ecology Theorists after all felt in order to get under the skin of a city to really know how it works you need to wear out as much shoe leather as possible.

My area for the past two years is what the Chicago School Theorists would term the zone of transition; an area near the very centre of the city with a transient population which serves as an arrival point for recent migrants. This would of course be a gross over-simplification of the dynamic of the area, where individual streets change in character from top to bottom, but provides a broad-brush stroked overview.

Many of the buildings are Victorian, built in the late 1800s and have, ironically through neglect, retained many original features. Many of the mosaiced paths leading to the front doors remain intact. Whilst not quite in the same league as Fishbourne they nevertheless are elegant, attractive features that put any homes built in the last 100 years to shame. Stained glass designs rest above doorways and many porches are brightened by ceramic glazed tiles in a multitude or shapes, colours and designs. No doubt conscientious owner occupiers would have long ago ripped these out to be replaced with whatever was de-jour. Another irony is it is the grandest of these homes, the victorian palaces at the end of tree lined streets abutting the main throughfare, which my Grandmother recalled as the posh part of town, that are now home to the most transient populations; their cavernous shells sectioned into single room dwellings.

Regeneration since the mid 1990s has transformed the area; once known as the red-light district. Investement in health centres and community facilities have been combined with City Patrol vehicles surveying the streets with mounted cameras and community based policing methods to reduce minor anti-social behaviour such as on-street drinking and drunkeness which had provided the area with its former reputation.

In the course of knocking on peoples doors the overwhelmingly majority were friendly even if many chose not to register to vote. Now, here is the difficulty with stage 3. My area has a very low response rate to Stages 1 and 2, in fact this year a response was not received from 593 properties which means potentially knocking on doors 1186 times. This is not just an issue for my feet, but is a huge problem for democracy. Anecdotally the people most reluctant to register are the most margianalised. Hardly any of the residents in the large houses sectioned into bed-sits register and many new eastern-europeans are also highly unlikely to register.

Working in local government I know that politics does matter, political decisions do impact our daily lives, particularly the lives of the most vulnerable who are more likely to be in contact with Health, Social Care, Housing and other services. Marginal groups and new immigrants are also vulnerable to being used as scapegoats for social problems by politicians eager to squeeze votes out of those who do register, but without registering to vote what hope do the marginalised have of having a voice to answer back?